| Allergen specific IgE each allergen CPT 86003 • Allergy | $6 | $6 | $6 |
| Allergen specific IgE qualitative multi-allergen CPT 86005 • Allergy | $7 | $8 | $10 |
| Percutaneous allergy skin test each allergen CPT 95004 • Allergy | $3 | $4 | $5 |
| Allergy testing insect venoms CPT 95017 • Allergy | $5 | $7 | $9 |
| Allergy testing drugs or biologicals CPT 95018 • Allergy | $9 | $17 | $25 |
| Intracutaneous allergy test each allergen CPT 95024 • Allergy | $9 | $9 | $9 |
| Allergen immunotherapy injection single CPT 95115 • Allergy | $10 | $12 | $14 |
| Allergen immunotherapy injection multiple CPT 95117 • Allergy | $12 | $13 | $14 |
| Allergen immunotherapy antigen preparation multi-dose CPT 95165 • Allergy | $3 | $4 | $5 |
| Anesthesia for salivary gland procedures CPT 00100 • Anesthesia | $30 | $55 | $80 |
| Anesthesia for eye procedures CPT 00140 • Anesthesia | $48 | $239 | $600 |
| Anesthesia for head and neck procedures CPT 00300 • Anesthesia | $30 | $49 | $68 |
| Anesthesia for chest wall procedures CPT 00400 • Anesthesia | $30 | $49 | $68 |
| Anesthesia for chest procedures CPT 00520 • Anesthesia | $30 | $173 | $420 |
| Anesthesia for lumbar region procedures CPT 00630 • Anesthesia | $48 | $219 | $540 |
| Anesthesia for abdominal wall surgery CPT 00840 • Anesthesia | $68 | $244 | $420 |
| Anesthesia for inguinal hernia repair CPT 00902 • Anesthesia | $30 | $231 | $600 |
| Anesthesia for total hip replacement CPT 01214 • Anesthesia | $68 | $503 | $900 |
| Anesthesia for total knee replacement CPT 01402 • Anesthesia | $80 | $453 | $800 |
| Anesthesia for hand and wrist procedures CPT 01630 • Anesthesia | $30 | $151 | $360 |
| Anesthesia for cesarean delivery CPT 01961 • Anesthesia | $30 | $55 | $80 |
| Anesthesia for epidural or spinal labor analgesia CPT 01967 • Anesthesia | $30 | $157 | $360 |
| Permanent pacemaker insertion CPT 33208 • Cardiology | $30 | $325 | $620 |
| Implantable defibrillator insertion CPT 33249 • Cardiology | $1,438 | $1,438 | $1,438 |
| Coronary artery bypass graft (CABG) single CPT 33533 • Cardiology | $2,919 | $2,919 | $2,919 |
| Coronary artery bypass graft (CABG) two grafts CPT 33534 • Cardiology | $30 | $2,045 | $3,497 |
| Coronary artery bypass graft (CABG) three grafts CPT 33535 • Cardiology | $3,826 | $3,826 | $3,826 |
| Percutaneous coronary angioplasty single vessel CPT 92920 • Cardiology | $835 | $835 | $835 |
| Percutaneous coronary stent single vessel CPT 92928 • Cardiology | $929 | $1,236 | $1,543 |
| Electrocardiogram (ECG) 12-lead CPT 93000 • Cardiology | $17 | $17 | $17 |
| Electrocardiogram tracing only CPT 93005 • Cardiology | $7 | $7 | $7 |
| Electrocardiogram interpretation only CPT 93010 • Cardiology | $10 | $10 | $10 |
| Cardiovascular stress test CPT 93015 • Cardiology | $85 | $85 | $85 |
| Cardiovascular stress test tracing only CPT 93017 • Cardiology | $52 | $52 | $52 |
| Holter monitor up to 48 hours CPT 93224 • Cardiology | $94 | $117 | $139 |
| External ECG recording up to 7 days CPT 93241 • Cardiology | $103 | $183 | $314 |
| Echocardiography transthoracic limited CPT 93303 • Cardiology | $201 | $237 | $272 |
| Echocardiography transthoracic complete CPT 93306 • Cardiology | $112 | $179 | $245 |
| Echocardiography transesophageal CPT 93312 • Cardiology | $30 | $427 | $1,083 |
| Stress echocardiography CPT 93350 • Cardiology | $30 | $70 | $109 |
| Left and right heart catheterization CPT 93452 • Cardiology | $222 | $251 | $280 |
| Left heart catheterization CPT 93458 • Cardiology | $1,554 | $1,615 | $1,676 |
| Left heart catheterization with ventriculography CPT 93459 • Cardiology | $945 | $1,183 | $1,422 |
| Duplex scan extracranial arteries CPT 93880 • Cardiology | $252 | $252 | $252 |
| Non-invasive physiologic study extremity arteries CPT 93922 • Cardiology | $100 | $118 | $136 |
| Duplex scan lower extremity arteries CPT 93925 • Cardiology | $242 | $271 | $301 |
| Duplex scan extremity veins complete CPT 93970 • Cardiology | $41 | $105 | $169 |
| Paring or cutting benign hyperkeratotic lesion single CPT 11055 • Dermatology | $48 | $65 | $74 |
| Paring or cutting benign hyperkeratotic lesions 2-4 CPT 11056 • Dermatology | $25 | $58 | $90 |
| Tangential biopsy of skin single lesion CPT 11102 • Dermatology | $151 | $151 | $151 |